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EPISTAXISEPISTAXIS

SPR TeachingSPR Teaching

Y RamakrishnanY Ramakrishnan

20 Oct 2010


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OVERVIEWOVERVIEW

AnatomyAnatomy

PathophysiologyPathophysiology

ManagementManagement

Difficult casesDifficult cases

1. Juvenile Angiofibroma1. Juvenile Angiofibroma2. Osler Weber Rendu2. Osler Weber Rendu


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INTRODUCTIONINTRODUCTION

CommonCommon

Most of the time, bleeding is selfMost of the time, bleeding is self--limited, but can often be serious and lifelimited, but can often be serious and life--threatening.threatening.

AetiologyAetiology1. Local1. Local

2. Systemic2. Systemic


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Common causesCommon causes

LOCALLOCAL Nasal trauma (nose picking)Nasal trauma (nose picking)

Atrophic rhinitisAtrophic rhinitis

Bleeding polyp of the septum orBleeding polyp of the septum orlateral nasal wall (inverted papilloma)lateral nasal wall (inverted papilloma)

Neoplasms of the nose or sinusesNeoplasms of the nose or sinuses

Vascular malformation eg JAFVascular malformation eg JAF

SYSTEMIC (VASCULAR)SYSTEMIC (VASCULAR) HypertensionHypertension

CoagulopathyCoagulopathy--platelets, clotting (drugs,platelets, clotting (drugs,disease)disease)

OslerOsler--WeberWeber--Rendu SyndromeRendu Syndrome


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Nasal Septal Blood SupplyNasal Septal Blood Supply

ExternalCarotid Artery

-Sphenopalatine artery-Greater palatine artery

-Ascending pharyngeal artery

-Posterior nasal artery

-Superior Labial artery

InternalCarotid Artery

-Anterior Ethmoid artery

-Posterior Ethmoid artery


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Source ofbleedingSource ofbleeding

ANTERIOR vs POSTERIOR

1.1. Anterior (Kiesselbach plexus): younger, usually septal vs. anterior ethmoid,Anterior (Kiesselbach plexus): younger, usually septal vs. anterior ethmoid,most common (>90%), typically less severemost common (>90%), typically less severe

1.1. Posterior (Woodruffs plexus): older population, usually SPA, more seriousPosterior (Woodruffs plexus): older population, usually SPA, more serious


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Initial ManagementInitial Management

ABCsABCs

Medical history/MedicationsMedical history/Medications

Vital signsVital signs

Physical examPhysical exam

Anterior rhinoscopyAnterior rhinoscopy

Rigid endoscope (3 pass)Rigid endoscope (3 pass)

BloodsBloods

Radiologic studiesRadiologic studies EUA noseEUA nose


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Treatment optionsTreatment options

Control of hypertensionControl of hypertension

Correction of coagulopathies/thrombocytopeniaCorrection of coagulopathies/thrombocytopenia

FFP or whole blood/reversal of anticoagulant/plateletsFFP or whole blood/reversal of anticoagulant/platelets

Cautery (AgNo3 vs. electrocautery)Cautery (AgNo3 vs. electrocautery) Nasal packingNasal packing anterior (merocel, rapidrhino)/posterior (Foley, Storz Epistaxisanterior (merocel, rapidrhino)/posterior (Foley, Storz Epistaxis

Catheter, Xomed Treace Nasal Post Pac)Catheter, Xomed Treace Nasal Post Pac)

Transexamic acidTransexamic acid

Floseal (collagen + topical bovine thrombin)Floseal (collagen + topical bovine thrombin)

Greater palatine foramen blockGreater palatine foramen block

SurgerySurgery arterial ligation (see later)arterial ligation (see later)

-- septodermoplastyseptodermoplasty

EmbolisationEmbolisation


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Traditional Posterior PackTraditional Posterior Pack


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Greater Palatine Foramen BlockGreater Palatine Foramen Block

Pterygopalatine injection of 2ml 2%lidocaine/1:80 000 Adr via greater palatinecanal

Mechanism of action is volumecompression/vasospasm of IMA inpterygopalatine fossa

Landmark greater palatine canal =1/2 waybetween 2nd molar tooth and midline palate

Do not insert needle more than 25mm(orbit, intracranial)

C

an help minimise bleeding during SPAligation


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Surgical treatment

Sphenopalatine artery ligationSphenopalatine artery ligation

Maxillary artery ligationMaxillary artery ligation--Transmaxillary IMA ligationTransmaxillary IMA ligation

--Intraoral IMA ligationIntraoral IMA ligation

Anterior Ethmoidal ligationAnterior Ethmoidal ligation

External carotid artery ligationExternal carotid artery ligation Septodermoplasty/Laser ablationSeptodermoplasty/Laser ablation

GENERAL PRINCIPLE:GENERAL PRINCIPLE:

PROXIMAL LIGATION =GREATER FAILURE RATE (ANASTOMOSIS)PROXIMAL LIGATION =GREATER FAILURE RATE (ANASTOMOSIS)


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SPA ligationSPA ligation


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SPASPA clip or diathermy?clip or diathermy?

A retrospective chart review of patients undergoing SPA surgery between January 1995A retrospective chart review of patients undergoing SPA surgery between January 1995and 2005 (CharingCross, London)and 2005 (CharingCross, London)

n=67 n =13 bilateral procedures, n=6 concomitant anterior ethmoid artery occlusion,n=67 n =13 bilateral procedures, n=6 concomitant anterior ethmoid artery occlusion,n=12 concomitant septoplasty.n=12 concomitant septoplasty.

n=8 patients significant early ren=8 patients significant early re--bleeding.bleeding.

C

onclusionC

onclusionPlatelet levels on admission and not using diathermy to occlude the sphenopalatinePlatelet levels on admission and not using diathermy to occlude the sphenopalatineartery were independent risk factors for rebleeding (P values .03, and .02, respectively)artery were independent risk factors for rebleeding (P values .03, and .02, respectively)

Not using diathermy was also an independent risk factor for late operative failure onNot using diathermy was also an independent risk factor for late operative failure onCox regression, reducing the mean reCox regression, reducing the mean re--interventionintervention--free interval from 94 +/free interval from 94 +/-- 7 to 327 to 32+/+/-- 7 months (P < .007; hazard ratio 6.4; 95% confidence interval 1.77 months (P < .007; hazard ratio 6.4; 95% confidence interval 1.7--24.9).24.9).

Laryngoscope. 2007 Aug;117(8):1452Laryngoscope. 2007 Aug;117(8):1452--6.6.

Outcome ofendoscopic sphenopalatine artery occlusion for intractable epistaxis: a 10Outcome ofendoscopic sphenopalatine artery occlusion for intractable epistaxis: a 10--yearyear

experience.experience. Nouraei SANouraei SA,, Maani TMaani T,, HajioffDHajioffD, Saleh HA, Mackay IS., Saleh HA, Mackay IS.


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Maxillary artery ligationMaxillary artery ligation


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Anterior ethmoid artery ligationAnterior ethmoid artery ligation

Usually postUsually post--traumatictraumatic

Lynch incisionLynch incisionFrontoFronto--ethmoid suture lineethmoid suture line

24 (AEA)24 (AEA)--12(PEA)12(PEA)--6 (ON)6 (ON)


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ECA ligationECA ligation

Not as effectiveNot as effective

Neck incisionNeck incision

ECA= branches, ICA =no branchesECA= branches, ICA =no branches

Separate XII, XI and X nerves, beware sympatheticsSeparate XII, XI and X nerves, beware sympathetics


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Angiography/EmbolisationAngiography/Embolisation

First presented as an alternative to surgery by Sokoloff et al in 1974 and consisted ofparticle embolization of the ipsilateral IMA.

Later refined by Lasjaunias stressing the need for a standardized angiographic andtherapeutic approach.

Indications

1. Poor surgical candidates2. Refractory epistaxis following surgery

3. Preoperative Juvenille angiofibroma

Success rates variable

Complications

1. stroke/blindness - when embolic material inadvertently enters the ICA or

OphA through anastomosis with ECA.

2. facial necrosis/numbness


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HEREDITARY HAEMORRHAGICHEREDITARY HAEMORRHAGIC

TELANGECTASIA (HHT) orTELANGECTASIA (HHT) or OslerOsler--WeberWeber--RenduRendu

Initially described as a familial disease with abnormal vascular structures causing bleedingInitially described as a familial disease with abnormal vascular structures causing bleeding

from the nose and GI tractfrom the nose and GI tract

18961896 -- Henri Rendu describes the first classic caseHenri Rendu describes the first classic case

19011901 -- Sir William Osler describes an inherited disease of inadequate vesselsSir William Osler describes an inherited disease of inadequate vessels

First to suspect liver involvementFirst to suspect liver involvement

19071907 -- Frederick Weber publishes extensively on the subjectFrederick Weber publishes extensively on the subject


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HHTHHT

Prevalence is 1Prevalence is 1--2 cases per 100,000 population2 cases per 100,000 population

Autosomal dominantAutosomal dominant -- mutations in Transferring Growth Factor (TGF)mutations in Transferring Growth Factor (TGF)--beta signalingbeta signaling

Endoglin and ALKEndoglin and ALK--1 (TGF1 (TGF--B) receptorsB) receptors

PresentPresent telangectasiatelangectasia

-- recurrent epistaxis (puberty/adulthood)recurrent epistaxis (puberty/adulthood)

-- internal lesions (GI bleeds,pulmonary AVM, liver, cerebral, spinal)internal lesions (GI bleeds,pulmonary AVM, liver, cerebral, spinal)

--Family historyFamily history

DxDx clinical (Curacao criteria)clinical (Curacao criteria)

--skin biopsy (dilated capillaries + new vessel in dermis)skin biopsy (dilated capillaries + new vessel in dermis)

IxIx--CT/MRI (pulmonary, CNS, liver AVMs)CT/MRI (pulmonary, CNS, liver AVMs)


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PathophysiologyPathophysiology

The end result is that postThe end result is that post--capillary venules enlarge and connect to enlargingcapillary venules enlarge and connect to enlargingarterioles, thus forming direct arteriolararterioles, thus forming direct arteriolar--venular connectionsvenular connections


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HHTHHT

Treatment optionsTreatment options

1.1. PreventionPrevention-- nasal saline/emollientnasal saline/emollient

2.2. Cautery/laserCautery/laser--KTP,Nd:YAG/surgicelKTP,Nd:YAG/surgicel

3.3. HormonalHormonal OestrogenOestrogen

4.4. SurgerySurgery septodermoplasty (replace nasal mucosa inc IT with SSG)septodermoplasty (replace nasal mucosa inc IT with SSG)

--Young procedure (close nasal cavity)Young procedure (close nasal cavity)

5.5. DXT/IMRTDXT/IMRT

6.6. Thalidomide (NEWThalidomide (NEW mouse model HHT)mouse model HHT)


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DXTDXT


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JUVENILE ANGIOFIBROMAJUVENILE ANGIOFIBROMA

Up to 0.05% of head and neck tumors

Occurring almost exclusively in male adolescents ? hormonal

Theories SPA/vidian origin

-incomplete regression 1st branchial arch artery (Schik et al 2009) origin

IMA/SPA, marker of early embryonic angiogenesis (Laminin 2)

Intracranial Extension between 10-20%

Surgery and DXT

Recurrence Rates as high as 50%

Regular surveillance


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Origin

Posterolateral nasal wall near sphenopalatine foramen

Medial growth

-Nasal cavity

- Nasopharynx

Lateral growth

- Pterygopalatine fossa

-Infratemporal fossa

Intracranial extension

a) PM fissure

posterior orbit

SOF

cavernoussinus (most common)

b) pterygoid process (vidian canal) sphenoid

(body + greater wing) foramen lacerum + ICA


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Histology

Myofibroblast is cell of origin

Fibrous connective tissue with abundant endothelium lined vascular spaces

Pseudocapsule of fibrous tissue

Blood vessels lack a complete muscular layer


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Diagnosis

History nasal obstruction, epistaxis, proptosis, visual loss, facial pain/numbness,intracranial

Physical Exam pink, non-ulcerated mass

Radiological study1. CT Scan

2. MRI

3. Angiogram


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Radiological Studies

CT Scan

-Excellent for bone detail

-Lesion enhances with contrast on CT

- Holman-Miller Sign -Characteristic anterior bowing of posterior maxillary wall MRI

-Soft tissue + intraacranial extension

- salt and paper = flow voids

Angiogram

-Evaluation of feeding blood vessels


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Radkowski Staging

Radkowski et al. Arch. Otolaryngology, 1996

LimitationLimitation not take into account origin from pterygomaxiallary fissurenot take into account origin from pterygomaxiallary fissure


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Presurgical - antiandrogen

Options: DES, flutamideOptions: DES, flutamide

Premise: in vitro (JNA tumor fibroblasts), volume shrinkage to facilitate surgicalPremise: in vitro (JNA tumor fibroblasts), volume shrinkage to facilitate surgicalexcisionexcision

Limited studies (n=11, 2 studies)Limited studies (n=11, 2 studies)

Conflicting results with flutamide:Conflicting results with flutamide:

a) Gates et al 1992a) Gates et al 1992 44% reduction (n=4/5)44% reduction (n=4/5)b) Labra et al 2004b) Labra et al 2004 11.1% reduction (n=6) over 6/5211.1% reduction (n=6) over 6/52

Labra A, ChavollaLabra A, Chavolla--Magaa R, LopezMagaa R, Lopez--Ugalde A, AlanisUgalde A, Alanis--Calderon J, HuertaCalderon J, Huerta--Delgado A. Flutamide as a preoperativeDelgado A. Flutamide as a preoperativetreatment in juvenile angiofibroma (JA) with intracranial invasion: report of 7 cases. Otolaryngol Head Necktreatment in juvenile angiofibroma (JA) with intracranial invasion: report of 7 cases. Otolaryngol Head Neck

Surg. 2004Surg. 2004

Gates GA, Rice DH, Koopmann CF Jr, Schuller DE. FlutamideGates GA, Rice DH, Koopmann CF Jr, Schuller DE. Flutamide--induced regression of angiofibroma Laryngoscope.induced regression of angiofibroma Laryngoscope.

1992 Jun;102(6):6411992 Jun;102(6):641--44


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Preoperative Embolization

Advantage volume reduction to faciliate complete excision Concern - ? Higher recurrence (tumor shrinkage into inaccesible cancelous bone)

24 to 72 hours preoperatively

Gelfoam or polyvinyl alcohol foam-Gelfoam: resorbed in approximately 2 weeks-Polyvinyl alcohol: more permanent

Efficacy-Stage I patients reduced from 840cc to 275cc blood loss

Complications- Brain and ophthalmic artery embolization

-Facial nerve palsy-Skin and soft tissue necrosis

Liu L et al. Analysis of intra-operative bleeding and recurrence of juvenile nasopharyngeal angiofibromas.

Clin Otolaryngol. 2002


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Surgical Approaches

Principles1. Adequate surgical approach

2. Control vascular supply IMA main feeder (behind tumour)

3. Lateral to medial dissection controlled and improved exposure of medial tumor

attachments (base pterygoid process/vidian canal)

4. Attention to microscopic residual tumor/prevention recurrence drilling vidian

canal/base pterygoid plate (Lloyd et al sphenoid invasion main predictor of recurrence)

Options Endoscopic transnasal

Transpalatal

Denker approach

Facial translocation

Medial maxillectomy

Infratemporal fossa with or without craniotomy

Lloyd G, Howard D, Lund VJ, Savy L. Imaging for juvenile angiofibroma. J Laryngol Otol. 2000 Sep;114(9):727-30


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Choosing the Surgical Approach

Smaller tumors (IA, IB, IIA, IIB, IIC)-Transnasal endoscopic

-Transpalatal

-Transantral: lesions extending laterally up to pterygopalatine fossa

Larger tumors (IIIA, IIIB)-Lateral rhinotomy-Midfacial degloving

Extensive resection with higher morbidity

Limited resection with higher recurrence

NOTE Extremely limited IIIA and IIIB may be approached endoscopically


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ChangingTechnique

Retrospective chart review of surgical intervention- 30 patients

Marked shift towards endonasal procedures while tumor stages remained thesame

Endonasal approach contraindicated in Stage IV and some Stage III cases

May be used in conjunction with other approach in these cases

Mann et al. Laryngoscope. 2004.


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Surgical Technique

Pryor et al. Laryngoscope. 2005

n=6 endoscopicn=6 endoscopic


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Surveillance

Recurrence Rates 20-50%

Frequent physical examinations

CT Scan / MRI


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Endoscopic Transnasal

Preop embolisation

Middle turbinectomy may be performed for

improved exposure

Middle meatus antrostomy

Resection of posterior maxillary wall

IMA/Sphenopalatine artery ligation

Tumor resection from pterygopalatine fossa


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Midface Degloving with Maxillary

Osteotomies


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External Beam Radiation

Retrospective review of efficacy of radiation as primary treatment modality for JNA

27 patients received 3000-5500 cGy

Recurrence rate of 15% 2-5 years post-treatment

External beam radiation is effective mode of treatment of advanced JNA

Lee JT et al. Laryngoscope. 2002


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External Beam Radiation

Long-term sequelae of concern

-panhypopituitarism (growth retardation), orbital complications (cataracts, posteriorcapsule opacification, optic atrophy), temporal lobe necrosis, malignant tumors

-reduced with IMRT?

Retrospective review reported 2 cases out of 55 patients developing secondarymalignancies

- Thyroid carcinoma 13 years after receiving 3500cGy

-Basal cell carcinoma of skin 14 years after receiving 3500cGy initially, then 3000cGyfor recurrence

Cummings et al. Laryngoscope 1984


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Conclusions

Rare, benign, vascular tumor found almost exclusively in young males

Surgery is the gold standard with a trend towards endoscopic approaches

Frequent follow-up after treatment is necessary


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QUESTIONS?QUESTIONS?


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AbstractsAbstracts

Clin Otolaryngol Allied Sci. 2002 Dec;27(6):536Clin Otolaryngol Allied Sci. 2002 Dec;27(6):536--40.40. Analysis of intraAnalysis of intra--operative bleeding and recurrence of juvenile nasopharyngealoperative bleeding and recurrence of juvenile nasopharyngeal

angiofibromas.angiofibromas. Liu LLiu L,,Wang RWang R,, Huang DHuang D,, Han DHan D,, Ferguson EJFerguson EJ,, Shi HShi H,,Yang WYang W..

Department of OtolaryngologyDepartment of Otolaryngology--Head and Neck Surgery, Chinese PLA GeneralHead and Neck Surgery, Chinese PLA GeneralHospital, Beijing, China. [email protected], Beijing, China. [email protected]

AbstractAbstract The purpose of this study is to present our experience with 34 patients diagnosed withThe purpose of this study is to present our experience with 34 patients diagnosed with

juvenile nasopharyngeal angiofibromas and treated in the Chinese PLA Generaljuvenile nasopharyngeal angiofibromas and treated in the Chinese PLA GeneralHospital between 1986 and 1999, and to examine the factors influencing intraHospital between 1986 and 1999, and to examine the factors influencing intra--operative bleeding and tumour recurrence. The age of the patient, the duration ofoperative bleeding and tumour recurrence. The age of the patient, the duration ofsymptoms and tumour stage were related to the amount of intrasymptoms and tumour stage were related to the amount of intra--operative bleeding.operative bleeding.The tumours were totally resected in 30 patients and recurred in five patients (16.7%),The tumours were totally resected in 30 patients and recurred in five patients (16.7%),

with a mean followwith a mean follow--up time of 77 months. The mean time to tumour recurrence afterup time of 77 months. The mean time to tumour recurrence afteroperation was 3.2 months (1operation was 3.2 months (1--6 months). The incidence of recurrence had no6 months). The incidence of recurrence had nocorrelation with the age of the patient, duration of symptoms, pericorrelation with the age of the patient, duration of symptoms, peri--operative treatmentoperative treatmentor surgical approaches (P > 0.05); but strongly correlated with tumour stage (P 0.05); but strongly correlated with tumour stage (P or = 30 patients), shorter lengthloss (225 vs. 1,250 mL), a lower occurrence of complications (1 patient vs. > or = 30 patients), shorter lengthof hospital stay (2 vs. 5 days), and lower rate of recurrence (0% vs. 24%).of hospital stay (2 vs. 5 days), and lower rate of recurrence (0% vs. 24%).

CONCLUSION: Endoscopic removal of JNA tumor appears to be safe and effective. Recurrence was notCONCLUSION: Endoscopic removal of JNA tumor appears to be safe and effective. Recurrence was notappreciably affected by approach.appreciably affected by approach.


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Herman 1999Herman 1999

Laryngoscope. 1999 Jan;109(1):140Laryngoscope. 1999 Jan;109(1):140--7.7.

LongLong--term followterm follow--up of juvenile nasopharyngeal angiofibromas: analysis ofrecurrences.up of juvenile nasopharyngeal angiofibromas: analysis of recurrences.

Herman PHerman P,, Lot GLot G,, Chapot RChapot R,, Salvan DSalvan D,, Huy PTHuy PT..

Department of Ear, Nose, and Throat Medicine, Hpital Lariboisire, Paris, France.Department of Ear, Nose, and Throat Medicine, Hpital Lariboisire, Paris, France.

AbstractAbstract

OBJECTIVES: Juvenile nasopharyngeal angiofibroma often recurs if the tumor is large. This report is a longOBJECTIVES: Juvenile nasopharyngeal angiofibroma often recurs if the tumor is large. This report is a long--term followterm follow--up of these cases. It establishes the prognostic values of tumor extensions, analyzes the anatomicup of these cases. It establishes the prognostic values of tumor extensions, analyzes the anatomic

factors involved in recurrences, describes the spontaneous evolution of remnants based on a radiographicfactors involved in recurrences, describes the spontaneous evolution of remnants based on a radiographicfollowfollow--up, and evaluates the pertinence of complex combined surgical approaches for invasive tumors and theup, and evaluates the pertinence of complex combined surgical approaches for invasive tumors and thevalue of complementary endoscopy.value of complementary endoscopy.

STUDY DESIGN: Retrospective review of 44 cases treated between 1985 and 1996.STUDY DESIGN: Retrospective review of 44 cases treated between 1985 and 1996.

METHODS: Statistical analysis of the correlation between recurrence and tumor extension as evaluated byMETHODS: Statistical analysis of the correlation between recurrence and tumor extension as evaluated bysystematic analysis of 18 putative tumor extensions on preoperative computed tomography scans.systematic analysis of 18 putative tumor extensions on preoperative computed tomography scans.

RESULTS: Invasion of the skull base affected twoRESULTS: Invasion of the skull base affected two--thirds of the patients, and the rate of recurrence was 27.5%.thirds of the patients, and the rate of recurrence was 27.5%.Extensions to the infratemporal fossa, sphenoid sinus, base of pterygoids and clivus, the cavernous sinusExtensions to the infratemporal fossa, sphenoid sinus, base of pterygoids and clivus, the cavernous sinus(medial), foramen lacerum, and anterior fossa were correlated with more frequent recurrence. Long(medial), foramen lacerum, and anterior fossa were correlated with more frequent recurrence. Long--termterm

radiographic followradiographic follow--up revealed putative residual disease in nine asymptomatic patients: these remnantsup revealed putative residual disease in nine asymptomatic patients: these remnantsgradually involuted.gradually involuted.

CONCLUSIONS: The data in the current study emphasize the prognostic value of skull base invasion and theCONCLUSIONS: The data in the current study emphasize the prognostic value of skull base invasion and thedifficulty of complete resection of extended lesions. Tumor remnants detected in symptomdifficulty of complete resection of extended lesions. Tumor remnants detected in symptom--free patients shouldfree patients shouldbe kept under surveillance by repeated computed tomography scan, since involution may occur. Recurrentbe kept under surveillance by repeated computed tomography scan, since involution may occur. Recurrentsymptoms may be treated by radiotherapy (30 Gy) rather than by extended combined procedures. Endoscopicsymptoms may be treated by radiotherapy (30 Gy) rather than by extended combined procedures. Endoscopicsurgery should be combined with surgery for better control of skull base extensions.surgery should be combined with surgery for better control of skull base extensions.

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